Laparoscopic Cholecystectomy for Large/Giant Gallstones: Case Report and Brief Review of Literature

Gallstones disease are the most common biliary pathology. Its prevalence in Nepal is found to be 4.87%. Giant/large gallstones have a higher risk of complications and presents technical difficulties during laparoscopic cholecystectomy. Open cholecystectomy is preferred in most of the cases with giant gallstones. With the availability of experience laparoscopic surgeon and modern laparoscopic equipment, laparoscopic cholecystectomy is also feasible in large/giant gallstones. We report 2 cases, one large gallstone in 51 years old female and one giant gallstone in 39 years old female each of which were successfully managed laparoscopically with uneventful post-operative period.

P-BN47 Acute cholecystectomy in elderly - Age is not a limit

Background Acute or hot cholecystectomy (AC) has been established as a safe and efficacious modality of managing acute biliary pathology. However, it has been performed with caution in the elderly (defined by the world health organisation as patients over the age of 65). The NICE guidance in this area does not preclude this practise on elderly patients. Our acute cholecystectomy service treats patients of all ages according to performance status and fitness for surgery rather than age we audited our results in this age group. Methods All patients over the age of 65 who underwent acute cholecystectomy in the dedicated emergency cholecystectomy lists were audited from the period starting 31st December 2019 to 31st June 2021. Patient demographics, co-morbidies and surgical factors were recorded. The primary outcomes measure was in hospital stay and re-admission, secondary outcome were complications and perioperative mortality. Results 41 elderly patients underwent AC during the audit period, (male 18: female 23). Majority of patients had acute cholecystitis 30(73%). The median inpatient stay following surgery was 2 days(range 2-5 days) and the median admission to surgery time was 6 days (range 5-12 days). Only 3(7%) patients had a subtotal cholecystectomy. There was only 3 complications from surgery which were all between a clavien-dindo score of 2 and 3. There were 3 readmission in the immediate post-operative period. There was one 30-day mortality which was from necrotising pancreatitis as a result of ERCP and not from the operation. Conclusions Acute cholecystectomy in this age group appears to be safe and effective way to treat acute biliary pathology and compares similarly to the outcomes in the younger groups.

O-EGS09 Effect of introducing an ambulatory care service on management of patients requiring acute cholecystectomy

Background Biliary pathology is a large tranche of the emergency surgical take, taking up many bed days, with many patients not receiving definitive management on their primary admission. An Emergency Surgical Ambulatory Care (ESAC) service was established at our hospital in 2019, aiming to provide a streamlined platform for diagnosis and surgical management of patients. Most notably this included patients with symptomatic gallstones which could be managed on a semi-urgent basis without hospital admission. We aim to analyse the efficiency of this novel service in hopes of identifying room for improvement so that we may enhance our patient outcomes. Methods Two time periods were retrospectively assessed; September-December 2018 (pre- ESAC) and September-December 2019 (six months after ESAC started). Patients with Cholelithiasis (ICD-K80) and Cholecystitis (ICD-K81) were identified, and those with either an incidental diagnosis of gallstones without symptoms, with gallstone pancreatitis, severe inflammation (empyema, gangrene, perforation), requiring ERCP or if they were unfit for surgery were excluded. Data was collected on number of admissions, length of stay and rate of cholecystectomy. Patients were divided into 2018 SAU, 2019 SAU and 2019 ESAC to compare the difference in their outcomes. Data are presented as median (range). Results Some 57 patients presented acutely in 2018 compared to 82 in 2019. The median wait to operation of 43.5 days in 2018 was significantly reduced to 7 days in 2019. Conclusions The introduction of an ESAC service in 2019 has allowed a reduction in number of admissions, total length of stay of patients and significantly reduced waiting time for surgery. Use of ESAC has shown to be more efficient in terms of hospital bed occupation and indirectly, utilization of resources. The high surgical success rate also ensures fewer patients re-presenting with the same pathology to the acute take and hence contributes to reducing strain on the on-call team. Further work is being done to reduce the number of patients presenting through the SAU pathway, and preferentially attending through ESAC.

Surgical Treatment of Gallstone Ileus: Less Is More

Introduction: The objective of this study was to evaluate the need for cholecystectomy in patients who underwent surgery for gallstone ileus. Methods: This was a retrospective review of the clinical history of patients who underwent surgery for gallstone ileus between December 1992 and December 2018 and follow-up until October 2020. Data regarding the surgical intervention, location of the obstruction, and surgical procedure performed were collected, as well as complications in relation to biliary pathology in the postoperative period. Results: Twenty-five patients underwent surgery for gallstone ileus. In all patients, except one, the site of the obstruction was identified. The mean age of the patients was 72 (standard deviation [SD] 13.3) years, with a female predominance (18: 7). The patients presented symptoms, on average, 2.9 (1–7) days before going to the emergency room; the primary symptoms were vomiting associated with abdominal pain and constipation (56%). Fifty-six percent of patients were diagnosed preoperatively by imaging tests. In 72% of patients, an enterolithotomy was performed alone without any other intervention on the gallbladder or bile duct. Eighty-three percent of the patients did not present any cholecystobiliary complications during the entire follow-up period, and urgent or delayed cholecystectomy was not performed after the acute episode. Conclusions: Gallstone ileus is a rare entity, and there are no randomized studies that support a preferred treatment. If surgical intervention is required, enterotomy for stone extraction is a safe and effective technique, and in our experience, urgent or delayed cholecystectomy is not necessary.

EP.FRI.472Building the ‘LIEGS’ way – Establishing an ambulatory Rapid Access Theatre Service for those patients with acute surgical pathology requiring operative management

Aim LTHT is the largest acute surgical unit in the UK and has seen an annual 11% increase in attendances with often 90 patients assessed daily. 40% patients present with acute biliary pathology but despite this there has been no dedicated operating list for this cohort of patients. Rapid Access Theatre (RAT) lists were created to manage these patients. We report our early results. Method In October 2020 the trust appointed four EGS Consultants forming a dedicated acute general surgical service. Emphasis was placed on creating ambulatory pathways and those patients safe to be managed at home but requiring surgical intervention are placed on a day case RAT list. COVID-19 has restricted the broad use of this service for all emergency admissions but biliary pathology continues to be amenable to these pathways. Data was collected retrospectively using in-house coding and electronic patient database systems. Results 34 day case laparoscopic cholecystectomies were performed in the first 10 weeks. Mean age was 44(17-67) with a male:female ratio of 1:1. Mean wait time from clinical review to theatre was 11(3-23) days. 1 patient required overnight admission but there were no readmissions and no reported complications at 30 days. Conclusion Despite isolation restrictions resulting from COVID-19, the service has allowed patients to be assessed and treated in a timely, safe fashion. The new service has resulted in significant reductions in bed stays and improved patient experiences. Financial savings have been clearly delineated and as such expansion of the model is underway.

TP6.2.5 Post-operative recovery following emergency laparoscopic cholecystectomy: a need to redefine the consent for emergency cholecystectomy

Aims Understanding the risks of emergency LC is necessary before patients can make an informed decision regarding operative management. Our primary aim was to provide a comprehensive analysis of the post-operative course of these patients. Methods Emergency LC performed for all biliary pathology across three surgical units between January 2015 and January 2020 were included. We followed each patient up for 100 days postoperatively and data was collected retrospectively. Data collected included demographic data, operative data, post-operative recovery, imaging, additional interventions and re-admissions. Results A total of 605 patients were identified (median age, 53 years (range 13-92); M:F, 1:2.7). 36.9% of patients had a complicated postoperative period, either suffering a significant complication, requiring prolonged post-operative stay (>3 days), further imaging, additional interventions or re-admission. The rate of complication was 13.5% (including retained stones 3.5%; collections 3.8%; bile leaks 3.3%). The rate of prolonged post-operative stay was 25.1%. 16.2% required postoperative imaging and 6.1% required post-operative intervention.12.9% were re-admitted for assessment related to the LC. The rate of bile duct injury was 0% (0/605). Conclusions Although LC has the reputation of largely an uncomplicated procedure, our data illustrates the substantive morbidity associated with emergency LC. Patients should be counselled about the high morbidity rates. This involves patient education and will improve consent which should help decrease litigation. Surgeons should take a more selective and pragmatic approach when offering the procedure.

EP.TH.649Identifying Factors Associated with Readmissions after acute biliary admission. Can it help prioritising patients in COVID recovery plans?

Aim We conducted a retrospective analysis of readmissions after Acute admission with biliary pathology managed conservatively under the Surgical Team in a teaching London Hospital from 01/03/2019-29/02/2020 Methods We obtained records of patients admitted with Acute Cholecystitis, Biliary Colic, Cholelithiasis, Choledocholithiasis and Gallstone Pancreatitis from the Audit Department between 01/03/2019-29/02/2020, and analysed these regarding patient demographics, comorbidities, duration of index admission, method of diagnosis and management and identified patients’ readmissions Differences in readmission rates based on before mentioned characteristics were studied. Results 157 patients presented between 01/03/2019-29/02/2020, 76 acute cholecystitis, 22 Biliary Colic, 24 Gallstone Pancreatitis, 6 Ascending Cholangitis and 29 Choledocholithiasis The highest representation rate was for patients with choledocholithiasis (41.3%) followed by Acute Cholecystitis (31.5%), 3 patients required cholecystostomies. Baseline characteristics and differences in these characteristics based on occurrence of readmission were studied. 45-60 age group, increasing comorbidity, and biliary obstruction were all associated with increased risk of readmission. Conclusion Readmissions is a substantial burden on the health care services and patient’s safety and QoL We propose adherence to the NICE/BSG Guidelines for management of Acute Biliary Disease, to alleviate this pressure which is already sometimes challenging due to the logistics and resources and would be more challenging with the COVID situation and limited emergency and elective theatre availability so the group at high risk of readmission should be prioritised in the recovery plans.

SP6.1.5 Morbidity following emergency and elective laparoscopic cholecystectomy for cholecystitis: a retrospective comparative cohort study

Aims A comprehensive comparison of post-operative outcomes between emergency and elective laparoscopic cholecystectomy (LC) for cholecystitis has not been conducted and the relative morbidity associated with emergency LC remains uncertain. Our aim was to evaluate the difference in early post-operative outcomes between emergency and elective LC for patients with cholecystitis. Method LC performed for cholecystitis across three surgical units between January 2015 and January 2020 were analysed retrospectively from multiple regional databases using deterministic records-linkage methodology. Rates of complications, further imaging, re-intervention, prolonged post-operative stay and re-admissions over a 100-day follow-up period were compared between emergency and elective groups using univariate and multivariate analysis. Results LC were performed for cholecysitits in 962 cases (median age, 52 years; M:F, 1:2.7; emergency:elective; 1:3.9). Emergency cholecystectomy had higher rates of complication (15.8% versus 8.8%;p<0.0001), prolonged post-operative stay (40.3% vs. 12.7%;p<0.0001), post-operative imaging and intervention (19.1% vs. 9.4%;p<0.0001) and readmission (11.1% vs. 7.0%;p=0.017). In the multivariate regression analysis, emergency LC was associated with prolonged admission (OR,5.7;p<0.0001), complication (OR,2.97;p<0.0001), post-operative imaging and intervention (OR,2.4;p=0.002) and readmission (OR,1.9; p = 0.06). Conclusions Despite current guidance, an emergency cholecystectomy remains a morbid procedure and we demonstrate increased risks of emergency LC versus elective LC. The increased risk of an emergency LC needs to be weighed up against the risk of further attacks from biliary pathology until elective surgery. Our data indicates that we need to readjust our selection criteria for the ‘emergency cholecystectomy patient’ and identify patients who will specifically benefit from earlier surgery.

Interventional radiology in rendezvous technique for choledocholitiasis in elderly patients

Aim. Define the safety and effectiveness of rendezvous technique for choledocholithiasis.Material and methods. We performed a retrospective and prospective analysis of the results in percutaneous transhepatic access to the bile ducts and endoscopic intervention in the rendezvous technique for choledocholithiasis in 100 elderly patients. The patients were divided into 2 groups for 50 people. The implementation of the rendezvous began from the antegrade stage in patients from group I; in patients of group II – from the retrograde stage. Postmanipulation complications and failures were When analyzed. The control point of the study is the identification of complications associated with manipulation from the next stages of the rendezvous technique.Results. We revealed a direct dependence of the results in sequence of rendezvous technique for elderly patients with choledocholithiasis and obstructive jaundice. This fact allows recommending percutaneous transhepatic access before endoscopic intervention for these patients with statistical significance. The frequency of complications and failures in patients of group I was 18%, in group II – 52%. This allows for such patients percutaneous transhepatic access before endoscopic intervention in the rendezvous technique. The frequency of complications and failures in patients of group I was 18%, in group II – 52%.Conclusion. Dilatation of intrahepatic segmental and subsegmental 2 and 3 biliary ducts with moderate and severe obstructive jaundice is a predictor of complications with ineffective endoscopic approach. In such situations, preventive antegrade drainage of the biliary tract with rendezvous technique makes possible to prevent cholangitis, effectively eliminate biliary hypertension, clarify the severity of stenosis of the papilla with antegrade balloon revision, and also secure delayed endoscopic resolution of biliary pathology.